In the news ... 2008

HIV Testing: taking the next step in California

July 21, 2008

In January 2008, California HIV testing law was modified by AB 682, which removed the requirement for written consent in order to reduce barriers to more routine testing in private medical centers. The law was based, in part, on guidelines for HIV testing released earlier by the Centers for Disease Control and Prevention (CDC). In the place of written consent, AB 682 requires the provider to inform the patient verbally that an HIV test is planned, provide information about the test, advise the patient that effective treatment options are available to those who test positive, that routine HIV testing is recommended for those testing negative and that the patient has the right to refuse the test.

Recognizing that implementation of new testing strategies requires more than a change in law, Project Inform worked with the California Department of Public Health/Office of AIDS (OA), the California Department of Public Health/STD Control Branch, the Pacific AIDS Education and Training Center, UCSF, the Los Angeles Office of AIDS Policy and Programs, and the San Francisco Department of Public Health to develop a strategy to meet the overarching goal of allowing all Californians the opportunity to test for HIV and know their HIV status. The organizers agreed that the first step was to design a meeting of diverse stakeholders focused on better understanding the opportunities and challenges associated with implementation of AB 682 and developing strategies to expand HIV testing effectively in the state.

HIV Testing: Taking the Next Step took place in late June with approximately 40 participants. The diversity and range of the participants was an important contributor to the success of the meeting. Representatives from diverse but traditional HIV test providers participated as did the California Family Health Council; the California Medical Association; the Department of Corrections and Rehabilitation; the California Primary Care Association; Emergency and Acute Care Hospital settings; Department of Public Health — Office of Family Planning; Kaiser Permanente; Maternal, Child and Adolescent Health, Department of Public Health; National Medical Association; and Planned Parenthood. The objectives of the meeting included:

• To identify current AB 682 implementation efforts;
• To identify gaps in efforts to expand implementation of AB 682;
• To identify barriers to implementation of AB 682;
• To discuss priorities for expanded testing;
• To identify strategies for targeting resources to expand implementation of AB 682; and
• To develop a draft action plan for further expansion of HIV testing in CA.

The meeting was organized to allow multiple opportunities for input and discussion by participants. Following introductory presentations on the state of HIV testing in California, participants were engaged in the discussion of several key questions in the large group and in smaller break out groups. The questions included:

• Given the current fiscal limitations, what are the priorities (population, risk group, client location, etc.) for HIV testing?
• What is the role of private health care in both HIV and non-HIV specific settings, in increasing HIV testing in California?
• What are the key barriers, issues, necessary policy changes or other factors related to reimbursement for HIV testing and/or resource allocation to expanded HIV testing?
• What are the key barriers, issues, necessary policy changes or other factors related to community readiness for expanded HIV testing (e.g., cultural, ethnic implications, etc.)?
• What are the key barriers, issues, necessary policy changes or other factors related to ensuring appropriate linkages to care following a presumptive and/or confirmed HIV positive test?

Some of the key issues identified by participants in efforts to expand HIV testing included:

• Individuals respond to questions about risk inaccurately – cultural issues and other reasons
• Inadequate funding for tests and administration
• Staff training and administrative issues re: testing need to be addressed in order to have testing become a part of routine screening
• De-stigmatization important
• Cross agency communication needed – public health to health system
• Emergency Departments - Need a separate, parallel system - not a lot of interest in integrating in current staff roles
• Linkage to care after diagnosis.
• Restrictions on public funding versus private funding
• Needs intra-agency policy communication to successfully implement in private medical settings
• Concerns re: OraSure reliability (false screening positives)
• Issues of state mandated phlebotomist training requirements presents barrier to easy blood draws for testing

By day’s end, strategies for building HIV testing throughout California and several statewide “next steps” were developed. They included:

• Develop consistent definition re: linkages to care
• Address Lab Field Services/Clinical Laboratory Improvement Amendment (CLIA) waiver
• Address phlebotomy regulations, including possible legislation
• Build an HIV testing implementation “toolkit”
• Address data collection issues
• Change training requirement for medical staff
• Develop a list of laws/changes needed to fully implement HIV testing
• A joint statement by relevant state entities encouraging expanded testing, identifying resources and linking to important web sites
• Work to ensure coverage of HIV screening by public and private payers
• California Department of Corrections “mandatory” or a “universal offer” in prison — need to link to implementation
• Address issues of undocumented residents and testing
• Documenting increased testing — look for ways to document the numbers of tests done in all settings throughout California
• Accessible Counseling and Testing trainings
• Easy access to technical assistance
• Warm line as a resource for implementation of testing?
• Education about billing codes for HIV test reimbursement
• Use of media, especially w/ success in the Latino community
• Non-rapid testing in primary care, or return visit settings as alternative
• Strategic planning workshops (as done in New Jersey)
• National Primary Care Association — sponsoring programs of testing in small areas.
• Look at effective non-traditional models, such as that at Los Angeles Gay and Lesbian Center

In addition to the overall next steps and strategies, individual participants developed their own goals for their work settings.

The conference provided a unique opportunity for those involved in the implementation of AB 682 to share experiences, consider challenges and opportunities, and to identify and evaluate strategies for expanding HIV testing in California. It was the first time that most of the organizations responsible for implementing new testing strategies had the opportunity to network and discuss concerns and achievements, and brainstorm possible solutions or recommendations. Next steps were identified, critical resources were disseminated, and many participants requested follow up meetings to continue to track progress and share ideas. Program evaluations were positive. Individual “take home” goals indicated that the participants are engaged in the process of expanding HIV testing in California with the ultimate goal of allowing all Californians to know their HIV status. The organizers of the meeting will convene in late July to evaluate the meeting and discuss next steps in the effort to expand testing and allow all Californians to know their HIV status. If you have any questions regarding this effort, please email .